Adolescent-parent communication on sexual and reproductive health issues and associated factors among high school students in Woldia town, Northeastern Ethiopia

Introduction Sexual and reproductive health (SRH) communication is most likely to promote healthy sexual practices and to reduce risky sexual behavior among adolescents. Communication is the principal means for parents to transmit sexual values and knowledge to their children. This study aimed to assess adolescent-parent communication on SRH issues among high school students in Woldia town. Methods A cross-sectional study was conducted from December 15-31, 2016. Systematic random sampling technique was used to select 693 students from Grades 9 and 10. Data were entered into Epi-info version 3.5.1 and analyzed by using SPSS version 20. Logistic regression with Odds Ratios (OR) and 95% Confidence intervals (CI) was used to identify the independent predictors of adolescent-parent communication. Results 674 students accepted to participate in this study giving a response rate of 97.3%. Only 205(30.4%) had discussed on two or more SRH topics with their parents. In logistic regression analyses, mothers who could read and write [AOR=2.0; 95% CI=1.3-3.1] and had diploma certificate [AOR=2.0; 95% CI=1.4-2.9] were more likely to discuss on SRH issues with their children. Adolescents who agreed on the importance of discussion on SRH issues [AOR=2.5; 95% CI=1.3-4.5], whoever got SRH information [AOR=2.0; 95% CI=1.4-2.9] and those whoever had sexual intercourse [AOR=1.7; 95% CI=1.1-2.6] were more likely to discuss on different SRH issues with their parents. Conclusion This study revealed that parent-adolescent communication on SRH issues was inadequate. Therefore, there is a need to equip and educate parents on different adolescents' SRH issues.


Introduction
An increased incidence of sexually transmitted disease (STD) including human immunodeficiency virus (HIV) infections in adolescents in developing and developed countries has led researchers to examine factors that influence young people's sexual behaviors [1]. Improving parent-adolescent communication at all community level is important and it is a current agenda to all concerned bodies in all country to promote healthy sexual behaviors of adolescents [2]. The world health organization (WHO) report on the analysis of adolescents SRH literature from different parts of the world informs that this concern has been largely driven by the high prevalence of HIV/AIDS among young people [3]. Though, sexual and reproductive health communication between parent and adolescent is a most important way of conveying sexual values and knowledge [4], discussions on sexual and reproductive health issues particularly sex-related matters are unacceptable and shame in most African countries [5] and parents believed that advising adolescents about sex-related issues and updating them how to abstain would make the adolescents sexually active [2,6]. Most youth-friendly services and health care providers in Ethiopia are not well prepared in addressing adolescents' sexual and reproductive health desires.
Hence, parents' communication with their children about SRH issues is important to enhance adolescents' awareness and to reduce their risky sexual behaviors [6]. Parent-adolescent communication on SRH issues in Ethiopia is believed to be socially disgraceful; moreover, parents are not open and uncomfortable to discuss these issues with their young children [7]. Parents' low level of knowledge about sexual and reproductive health issues makes open discussions with their children challenging. Nevertheless, as different studies revealed that home is the preliminary place to educate adolescents about SRH issues, and it is the first social environment for them [5].
Different Studies revealed that adolescents in Ethiopia have very low health-seeking behavior mainly to their SRH matters and even the current reproductive health services are not adolescent-centered [6,8]. Furthermore, health care workers in Ethiopia are not well prepared to address adolescents' SRH desires [8]. Hence, the involvement of families, community members, and other stakeholders is important to improve the health status of the adolescents [9]. Thus, families, as primary socializing agent and live models for their children need to play an important role in shaping the sexual life of their adolescents and to reduce their burden of diseases and disabilities associated with SRH [6,10]. However, not much support is offered for parent-adolescent communication, and parents often do not discuss with their children because they feel confused, ill-informed, or embarrassed about SRH topics [11]. Even though the Ethiopian government has identified the reproductive health of adolescents as one of the priority areas in the national RH Strategy taking the households and community as vehicles for change, it is not yet put in practice [12]. Parental discussion about adolescents' SRH matters is very important perhaps now than any other time. This is because adolescents are affected by the burden of unwanted pregnancy and its complication, HIV/AIDS, sexual transmitted infections (STIs) and other sexual and reproductive ill health to a greater extent [6,13]. Therefore, the aim of this study was to determine adolescent-parent communication level on SRH issues and to assess associated factors among high school students in Woldia town, Northeastern Ethiopia.

Study area and period:
The school-based cross-sectional study was conducted among high school students in Woldia town, North Wollo Zone, Amhara Regional State from December 15-31, 2016.
Woldia town is located in the Northeastern part of Ethiopia at 521km from the capital city, Addis Ababa. According to 2007 Ethiopian population census report, the total population of the town was 46,139 with sex distribution of 49.8% "males" and 50.2% "females". Moreover, from the total population, 13,027(28%) found in the age group of 15-24 for both sexes [14]. The town has two high schools namely Woldia high school and Millennium high school in which grade 9 and 10 education is delivered. Accordingly, Woldia high school and Millennium high school had a total of 1,844 and 1,195 students during the study period, respectively. There are one hospital and two health centers in the town, but there are no wellequipped youth friendly centers.

Study population:
The study population was all students of grade 9 and 10 of both high schools in Woldia town during the study period. Unmarried adolescents in the age group 15-24 years were included in the study. The sick, visually impaired and those unwilling to participate were excluded from the study.
Sampling procedures: A multi-stage sampling technique was used. Simple random sampling was used to select the sections from each grade in the two schools. To select the study unit, students" roster was used as a sampling frame. To determine the number of students from each grade, proportional allocation to their size was used and in every step, a simple random sampling technique was used to select the grade and students from each section. Finally, the study subjects were selected using simple random sampling technique. preferably who has experience of data collection were selected.

Study variables
Confidentiality and privacy were given attention during training and the trainees participated during pre-testing of the questionnaire.
The aim of the study was explained to the selected adolescents. To ensure the quality of the data, all the filled questionnaires were checked for incompleteness and inconsistency. The investigator also discussed with the supervisors on how to supervise the data collectors and how to solve problems encountered during the data collection process. Data collectors were supervised by B.Sc degree holder nurses. Moreover, pre-test was conducted on 10% of all the total sample size from other high school to ensure its completeness and consistency in providing the information needed for the study.
Data processing and analysis: In this study, the term "parentadolescent communication on SRH issues refers to parents opening a discussion on SRH issues or parental involvement in SRH discussion initiated by the adolescents or both". It was measured with a "Yes" for those who had a parental discussion and a "No" option for those who had no parental discussion. Data were coded, edited, and entered using EPI Info version 3.  (Table 6). Adolescents, whose mothers could read and write were 2 times more likely to communicate on SRH issues with their parents than those students whose mothers could not read and write (AOR = 2.0; 95% CI: 1.3-3.1); similarly, Students whose mothers had diploma certificate were 2 times more likely to communicate on SRH issues with their parents than those adolescents whose mothers were illiterate (AOR = 2.0; 95% CI: 1.4-2.9). Adolescents, who had positive perception on the importance of discussion on SRH issues with their parents were 2.5 times more likely to discuss on SRH issues than those who did not agree the importance (AOR = 2.5, 95% CI: 1.3-4.5). Those students whoever got SRH information were 2 times more likely to communicate on SRH issues with their parents than those who never got SRH information (OR = 2.0; 95% CI: 1.4-2.9). This study also revealed that those adolescents whoever had sexual intercourse were 1.7 times more likely to communicate on SRH issues with their parents than those who never had sexual intercourse (AOR = 1.7; 95% CI: 1.1-2.6) ( Table 6).

Discussion
In However, our figure is higher than a study conducted in Bullen, Ethiopia (29%) [13], Lesotho (20%) [10], Awabel, Ethiopia (25.3%) [6], but, lower than the study conducted in Dire Dawa, Ethiopia (37%) [16], Debre Markos, Ethiopia (36.9%) [17], Yirgalem, Ethiopia (59.1%) [18] and Zimbabwe (44%) [19]. However, a study  [20], however, the majority of adolescents preferred to discuss with their peers than their parents [20]. This is consistent with the report by Ayehu and his co-authors, 431(57.8 %) of adolescents had SRH discussion with their peers than parents [6]. This is due to the fact that peers may become more powerful sexual socialization agents than parents, particularly for information about sexual intercourse [5]. In contrast, Markos, Ethiopia [17]. Those adolescents whose mothers could read and write were more likely to communicate SRH issues with their parents than those students whose mothers were illiterate. This is in line with the study conducted from Hawasa, Ethiopia [15] and in Debre Markos, Ethiopia [17]. This may be due to the difference in mothers' knowledge on SRH issues, communication skills, perceived the importance of discussion on SRH issues, and access of information about sexual and reproductive health issues.
Adolescents who believed on the importance of discussing SRH matters with their parents were more likely to discuss SRH issues than those who had not believe the importance. This may be due to students' perception difference on the importance of discussion on different SRH issues with their parents. A similar result had reported from Debre-Markos, Ethiopia [17]. Those students whoever got SRH information were more likely to communicate SRH issues with their parents than those who never got SRH information. This may be due to that adolescents who had SRH information would be more aware and keen to discuss SRH issues and the information they got may gave the way for initiation of communication. The study revealed that those adolescents whoever had sexual intercourse were more likely to communicate on SRH issues with their parents than those who never had sexual intercourse. This may be due to fear of risks come as a result of sex and exploration habits of the adolescents.

Conclusion
In this study parent-adolescent communication on SRH issues was inadequate. Adolescents whose mothers could read and write and adolescents whoever got SRH information had communication on

Acknowledgments
Our sincere gratitude goes to Woldia University, Faculty of Health Science for all supports. We would like to acknowledge the study participants for their participation in this study.